When the Stars Align and Your Patient is in Sync: Adherence Rises

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2 When the Stars Align and Your Patient is in Sync: Adherence Rises ACTIVITY DESCRIPTION Using the example of an elderly diabetic patient with co-morbidities, this presentation reviews how community pharmacies and patients benefit from Star ratings and synchronizing patient medications. Since pharmacists make the strongest contributions to the Star performance measures that are weighted most heavily for medication use and adherence, knowledge in this area is critical to maintaining preferred provider status. This is especially critical in 2015 as all ACA health plans will be evaluated on adherence measures. TARGET AUDIENCE The target audience for this activity is pharmacists, pharmacy technicians, and nurses in hospital, community, and retail pharmacy settings. LEARNING OBJECTIVES After completing this activity, the pharmacist will be able to: Describe the Star Ratings Scale, and its role in reimbursement for the ACA health plans, as well as its impact on community pharmacies. Understand the role of the community pharmacist with regards to increasing their individual facility s adherence measures. Identify the benefits of a medication synchronization program for both the community based pharmacy practice, as well as the patients of that practice. After completing this activity, the pharmacy technicians will be able to: Describe the Star Ratings Scale, and its role in reimbursement for the ACA health plans, as well as its impact on community pharmacies. Identify the benefits of a medication synchronization program for both the community based pharmacy practice, as well as the patients of that practice. ACCREDITATION Pharmacy PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Nursing PharmCon, Inc. is approved by the California Board of Registered Nursing (Provider Number CEP 13649) and the Florida Board of Nursing (Provider Number ). Activities approved by the CA BRN and the FL BN are accepted by most State Boards of Nursing. CE hours provided by PharmCon, Inc. meet the ANCC criteria for formally approved continuing education hours. The ACPE is listed by the AANP as an acceptable, accredited continuing education organization for applicants seeking renewal through continuing education credit. For additional information, please visit: Universal Activity No.: H04-P Credits: 1.0 contact hour (0.1 CEU) Release Date: 01/01/2015 freece Expiration Date: 06/30/2016 ACPE Expiration Date: 06/18/2018 ACTIVITY TYPE Knowledge-Based Live Webinar FINANCIAL SUPPORT BY Merck

3 Mark Garofoli, PharmD, MBA, CGP Adjunct Assistant Professor & MTM Program Manager, WVU Research Corp. & School of Pharmacy ABOUT THE AUTHOR Mark graduated from the University of Pittsburgh earning a PharmD in 2004, and later went on to earn an MBA from Strayer University in Mark is certified in Geriatrics (CGP), Immunizations, Medication Therapy Management (MTM), and Weapons of Mass Destruction (WMD) Response. He resides with his lovely wife, Gretchen Garofoli (also a FreeCE.com presenter), in Morgantown, WV where he is an adjunct assistant professor at the West Virginia University School of Pharmacy and the Medication Therapy Management Program Manager. FACULTY DISCLOSURE It is the policy of PharmCon, Inc. to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer of any commercial product(s) and/or service(s) discussed in an educational activity. Mark Garofoli reports no actual or potential conflict of interest in relation to this activity. Peer review of the material in this CE activity was conducted to assess and resolve potential conflict of interest. Reviewers unanimously found that the activity is fair balanced and lacks commercial bias. Please Note: PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced and objective. Occasionally, faculty may express opinions that represent their own viewpoint. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not intended as a substitute for the participant s own research, or for the participant s own professional judgement or advice for a specific problem or situation. Conclusions drawn by participants should be derived from objective analysis of scientific data presented from this activity and other unrelated sources. Neither freece/pharmcon nor any content provider intends to or should be considered to be rendering medical, pharmaceutical, or other professional advice. While freece/pharmcon and its content providers have exercised care in providing information, no guarantee of it s accuracy, timeliness or applicability can be or is made. You assume all risks and responsibilities with respect to any decisions or advice made or given as a result of the use of the content of this activity.

4 Peter Kreckel, RPh Adjunct Assistant Professor, Saint Francis University ABOUT THE AUTHOR "Professor Pete" Kreckel is a practicing retail pharmacist who works in Altoona Pennsylvania. Both he and his wife, Denise are 1981 graduates of the University of Pittsburgh School of Pharmacy. He has worked independent retail pharmacy for over 30 years. He has been teaching Pharmacology in the Physician Assistant program at St. Francis University since He has been a regular PharmCon favorite since 2008 covering topics of primary interest to the retail pharmacist. He was inducted into Pi Alpha the Physician Assistant honorary fraternity, and was named as "Preceptor of the Year" by the Pennsylvania Pharmacists Association for his dedicated work to the education of pharmacy students from Duquesne University, and from his Alma mater the University of Pittsburgh. Professor Kreckel was recently named the 2014 Preceptor of the Year by the NCPA! FACULTY DISCLOSURE It is the policy of PharmCon, Inc. to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer of any commercial product(s) and/or service(s) discussed in an educational activity. Peter Kreckel reports no actual or potential conflict of interest in relation to this activity. Peer review of the material in this CE activity was conducted to assess and resolve potential conflict of interest. Reviewers unanimously found that the activity is fair balanced and lacks commercial bias. Please Note: PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced and objective. Occasionally, faculty may express opinions that represent their own viewpoint. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not intended as a substitute for the participant s own research, or for the participant s own professional judgement or advice for a specific problem or situation. Conclusions drawn by participants should be derived from objective analysis of scientific data presented from this activity and other unrelated sources. Neither freece/pharmcon nor any content provider intends to or should be considered to be rendering medical, pharmaceutical, or other professional advice. While freece/pharmcon and its content providers have exercised care in providing information, no guarantee of it s accuracy, timeliness or applicability can be or is made. You assume all risks and responsibilities with respect to any decisions or advice made or given as a result of the use of the content of this activity.

5 When the Stars Align and Your Patient is in Synch: Adherence Rises Activity ACCREDITATION Universal Activity Number L04 Activity INSTRUCTION Faculty Credits 1.0 contact hour(s) Peter Kreckel, RPh Adjunct Asst. Prof. of Pharmacology, St. Francis University Mark Garofoli, PharmD, MBA, CGP Humana Healthcare Faculty Disclosure Prof. Kreckel and Dr. Garofoli have no actual or potential conflicts of interest in relation to this activity. Learning OBJECTIVES Describe the Star Ratings Scale, and its role in reimbursement for the ACA health plans, as well as its impact on community pharmacies Understand the role of the community pharmacist with regards to increasing their individual facility s adherence measures Identify the benefits of a medication synchronization program for both the community based pharmacy practice, as well as the patients of that practice Legal DISCLAIMER The material presented here does not necessarily reflect the views of PharmCon, Inc. or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity. FACULTY: Peter Kreckel, RPH and Mark Garofoli, PharmD, MBA, CGP 12/29/ Learning objectives Our Patient Understand the role of the community pharmacist with regards to increasing their individual facility s adherence measures. Describe the Star Ratings Scale, and its role in reimbursement for the ACA health plans, as well as its impact on community pharmacies. Identify the benefits of a medication synchronization program for both the community based pharmacy practice, as well as the patients of that practice. Betsy is a 75 year-old woman visiting your pharmacy today because of the lightning pain in her legs and her high sugar, which her prescriber gave her a prescriptions for Lyrica & Victoza respectively today. Based on refill records, Betsy has not been adherent to any of her medications metformin ER 500mg (1 tablet twice daily) glipizide ER 10mg (1 tablet daily) 12/29/ /29/

6 What is Medication Adherence? Medication Adherence: The patient s conformance with the provider s recommendation with respect to timing, dosage, and frequency of medicationtaking during the prescribed length of time Compliance: Patient s passive following of provider s orders Persistence: Duration of time patient takes medication, from initiation to discontinuation of therapy National Medication Report Card In the past 12 months did the patient: Fail to fill or refill a prescription Miss a dose Lower or higher dose than prescribed Stop a prescription early old medication for a new problem Take someone else s medicine Forgot whether they d taken a medication Overall National Grade: C+ Non-Adherence costs the nation $290 BILLION annually /29/ /29/ Measuring Adherence Major Barriers to Adherence Medication adherence scales Morisky-8 (MMAS-8) Morisky-4 (MMAS-4) Medication Possession Ratio (MPR) Proportion of Days Covered (PDC) Health Literacy Cost The Buy In Routine/Forgetful Adherence Programs Pfizerpfh.com (Pfizer Prescription for Health) MerckEngage.com (Merck) 12/29/ /29/

7 Literacy Pharmacists have come a long way Health Literacy Nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely available in our health care facilities, retail outlets, media, and communities. 1 Literacy 21% of U.S. Adults either read below 5 th Grade level or cannot read at all. 2 You sell the toothpaste. I ll write the prescriptions. (1979) Is this what your patients interpret from our label instructions? 1. (Kutner et al., 2006) 2. April 2013 Study by U.S Department of Education & The National Institute of Literacy. 12/29/ /29/ Cost The Buy-In $10 co-pay increase decrease 10% compliance -12% Free Clinic Meds still in pickup bins though??? -12% -29% RX Prescribed RX Filled RX Taken RX Continued Realizing Importance and impact of prescribed medication for longer & healthier life /29/ /29/

8 Adherence Rates for Specific Disease States Disease state Adherence Rate HIV disease 83.3% Cancer 79.1% Primitive Adherence Reminders Plastic pill reminders Cell phone alarm reminders Even my flip phone has a pill alarm reminder Diabetes 67.5% Asthma 50% Gout 37% 12/29/ /29/ Novel Adherence Reminders Smart Pill Take tracking pill along with other pills Data receiver is a necklace Helius Data receiver is a body patch Also tracks heart rate, temperature, etc. Vitality GlowCap Inside the cap, a chip monitors when the pill bottle is opened and transmits message via AT&T. Enters medication schedule online, the pill cap glows and plays a melody when it s time to take a pill. SMRxT Round Device placed in bottom of pill bottle, weighs pills left, transmits message via Verizon. Medminder The pillbox connects via satellite (not internet/phone). It has multiple trays Sends reminders if patients don t open the trays UBox MedCenter Novel Adherence Reminders GeckoCap Kids use the Smart Inhaler Cap Parents use the dose tracking Cool features to encourage kids to keep up with their medications. Smart Bottles Adhere Tech (Cloud Based) Didit! (Manual clicker on bottle) Unit Dose Bundles Parata Pass Packs Medicine on Time 12/29/ /29/

9 Nbr of PDP Plans Nbr of MA Plans Script Your Future Adherence Reminders Adherence Apps Take Medicatio n 12/29/ /29/ Back to Our Patient Betsy Betsy is a 75 year-old woman visiting your pharmacy today because of lightning pain in her legs and her high sugar, which her prescriber gave her a prescriptions for Lyrica & Victoza respectively today. When the STARS Align Star Rating PDP Plans Per Star Rating 2013 & Star Ratings What do the Star Ratings Mean 1 Plan Quality Performance Excellent Above Average Average Below Average Poor Medicare Advantage Plans Per Star Rating 2013 & Star Ratings /29/ /29/

10 Medicare Plan Star Ratings 53 measures rated from 1 to 5 Stars Each measure weighted from 1 to 3 on importance Medicare plans can get financial bonuses for increasing adherence metrics Beneficiaries can enroll in 5-star plans at any time during the year Medicare Plan Star Ratings Pharmacy Specific Performance Measures Advantage Plans Appropriate Screenings & Vaccinations Complete Medication Reviews (CMRs, baseline 2015) Prescription Drug Plans (Part D Plans) High risk medication use in the elderly (HRME) ACE-I/ARB use in patient with diabetes*** Appropriate Screenings and Vaccinations Adherence 12/29/ /29/ Medication Adherence is a Star Measure 3 out of the 17 (almost 20%) Measures are Adherence Adherence to oral diabetes medications Adherence to hypertension medications Adherence to cholesterol medications Current Plan Ratings 2014 Star Measures MAP-D PDP HRME 7.8% 8.8% ACE-I/ARB in DM 84.3% 82.3% Adherence (DM) 73.7% 75.8% Adherence (BP) 73.9% 76.8% Adherence (Statins) 69% 71% 12/29/ /29/ *JAPhA 54:3, May/June 2014, p

11 Equipp Electronic Quality Improvement Platform for Plans and Pharmacies Started from a Quality Alliance project in Pennsylvania between Highmark and Rite Aid Pharmacy Performance information management platform Compare their ratings to established benchmarks and other pharmacies within their chain or independent pharmacy company Connect to resources that help to improve. Cardinal Health is sponsoring a pilot project with 600 of its retail pharmacy customers, with plans for expansion. 12/29/ Professor Pete s Pharmacy First Report Card Oral Diabetes Medications Adherence 86.7%: 5 Star (5 Star Goal: 77%) Hypertension Medications (RASA) Adherence 73.8%: 3 Star (5 Star Goal: 79%) Cholesterol (Statins) Medication Adherence 73%: 4 Star (5 Star Goal: 75%) Treatment of Hypertension in Persons with Diabetes 75%: 3 Star (5 Star Goal: 87%) High Risk Medications in the Elderly 8.3%: 3 Star (5 Star Goal: </= 3%, lower is better) 12/29/ NCPA Adherence Impact Calculator Gross profit per prescription: In 2010, the average gross profit per prescription drug was $13.80 The average patient with a chronic condition utilizes approximately 3 different chronic medications. For many non-adherent patients it will take days to refill a 30 day medication. A very good goal is to identify 2 patients each business day that are on maintenance medications. What ONE adherent patient can do for your pharmacy. No Adherence Program Refill every 40 days, yields 9.1 refills per Rx per year $13.80 X 3Rx X 9.1 Refills per year = $376.74/year With Adherence Program Refill every 30 days, yields 12 refills per Rx per year $13.80 X 3Rx X 12 Refills per year = $496.80/year $120.06/year increased gross profit per patient. Possibly paying for a full time tech??? 12/29/ /29/

12 APhA Foundation s Align My Refills Program Pharmacist Roles Review all medications Recommend any necessary changes to medications Proactively refill medications Outcomes for Patients Fewer trips and refill calls to the pharmacy Relieved Worries of never running out of medications Monthly opportunity to discuss medications with pharmacist APhA Foundation s Align My Refills Program Pharmacist Roles Review all medications Recommend any necessary changes to medications Proactively refill medications Outcomes for Patients Fewer trips and refill calls to the pharmacy Relieved Worries of never running out of medications Monthly opportunity to discuss medications with pharmacist 12/29/ /29/ Appointment Based Model (ABM) Core Components Prescription synchronization Monthly phone call to the patient Monthly appointment with the patient Appointment Based Model (ABM) National Alliance of State Pharmacy Associations (NASPA) Study 57% of non-persistent patients became persistent Pharmacy averaged 2 additional refills per patient per year USA Drug Survey 80% of respondents stated being more likely to take their medications because of the ABM 100% of respondents liked the ABM and would recommend to friends/family /29/ /29/

13 Our first plan of attack the 12% Remember that 12% of the prescriptions from the providers are NOT picked up Using the platform we have one tech assigned to the pick up bins. Each day the tech covers 1/5th of the pick up bins. Keys in the phone numbers of each Rx that is 3 days old, then 10 days. Automated system calls patients with pre-recorded message with Pete s voice. After 2 calls, return prescription to stock. So.. How is the pick up rate?? Working EXTREMELY well. Rather than a haphazard approach, all parameters are defined, 3 day reminder, 10 day reminder, then return to stock Get an average of 5 returned calls per day and patients do pick up the meds, or request delivery. Some patients tell us they don t need the meds (antibiotics, anti-nausea meds) 12/29/ /29/ Getting Patients in Sync Medication Synchronization Med Sync Pharmacist coordinates the refill of all medications so the patient can pick them up on a single day each month 1 Consumers enrolled in medication synchronization services were 3 to 6 times more adherent to their medications than consumers who were not enrolled. 1 Medication non-adherence for their first refill was reduced over 90% for patients participating in med sync. 1 Nearly 90% of patients who received synchronized refills were considered adherent compared with 56% of patients not receiving synchronized refills. 2 Med Sync Operational Plan Invite patients into ABM program (Phone/Face) Create a patient chart Anchor with highest cost medication Short fill other medications Small quantities hold over until mutual medication date Fax/Call prescribers to request short fills Document in patient chart Schedule appointment with patient for complete medication review (CMR) and/or pickup 1: APhA Foundation 2: Drugstore.com 12/29/ /29/

14 Med Sync Operational Plan Example Medication Directions Day Supply Last Fill Next Fill Metoprolol 25 1 BID 60 5/9 6/8 Xarelto 20mg 1 QD 30 5/20 6/19 Sertraline 50mg 1 QD 30 5/29 6/28 HCTZ 25mg 1 QD 30 5/12 6/11 Simvastatin 20mg 1 QD 30 5/15 6/14 Anchor with highest cost medication (Xarelto ) Short fill other medications 8 hctz tablets, to move fill date from 6/11 to 6/19 (then 1 month) 21 sertraline tablets, to move fill date from 6/28 to 7/19 22 metopolol 25mg, to move fill date from 6/8 to 6/19 5 simvastatin tablets to move fill date from 6/14 to 6/19 Use a calendar to improve accuracy 12/29/ How do we short fill Our store policy: Just give them the extra pills! Our computer does count down by the number of tablets. SUBMISSION CLARIFICATION CODES RELATED TO SHORTENED DAYS SUPPLY FOR PURPOSES OF TRIAL OR SYNCHRONIZATION FILLS 47 - Shortened Days Supply Fill only used to request an override to plan limitations when a shortened days supply is being dispensed Fill Subsequent to a Shortened Days Supply Fill only used to request an override to plan limitations when a fill subsequent to a shortened days supply is being dispensed 12/29/ Prescribe Wellness Pharmacy Growth Program Personalized and recorded messaging system to improve your patients knowledge, understanding and performance. (i.e. new patient welcome, missed refills, Happy birthday, vaccines, etc.) Peak Wellness Program Chronic conditions Star Wellness Program Med Sync (Anchor medication calculator) Transitional Care Program Pharmacy/Hospital collaboration Back to Our Patient Betsy Betsy (75yo, DM2, Neuropathy, etc.) did not refill her Victoza and Lyrica due to high copays and still does NOT take her medications consistently Discuss switch of Lyrica to gabapentin with prescriber Start low & go slow dosage Discuss role of Victoza (along with current medications of metformin and glipizide) in reducing future diabetic organ complications and preventing her lightning pain Request samples or discount cards for Victoza and Lyrica. MED SYNC!!! 12/29/ /29/

15 Med Sync Benefits for Betsy Med Sync Benefits for RPhs Extremely high sugar levels AFTER a meal are responsible for MACROvascular complications Cardio/amputation Elevated blood sugar levels BEFORE a meal are responsible for MICROvascular complications Blindness/kidney failure/dpn $$$ Med Sync 3-6x>refills, ~$10 Each MTM Program Reimbursements Better inventory management Less need for paying to keep high cost meds on your shelves Stress Reduction No more refills on Monday morning or rush hour 12/29/ /29/ Optimal med sync patients Who wouldn t like med sync? Free Delivery Example: Rose 78 year old patient. Daughter comes in to transfer from another pharmacy. I did a med synch for a fill date of 26 th of the month. Daughter calls and says you are the answer to our prayers HIV Patients All 6 of my HIV patients are enrolled in med synch. Cost of meds is around $4000/month. ($24k/ month; 288k/year) not sitting on shelf (1 turn on inventory). Anyone on a predictable stable medication regimen COPD patients, Chronic pain patients, and Diabetics can be a challenge. Phil & Sarah- he s retired, and she uses frequent trips to pharmacy to get him out of the house. You can entertain him Linda- Lives alone gets free delivery 2-3 times per week. Is disabled and wants someone to check on her Kathy- diabetic on insulin, can t synch her test strips, lancets, needles, insulin. Annie- I d like to, but I cant afford all of the copays at once Brent- The psych doc is always changing my meds 12/29/ /29/

16 Medication Therapy Management (MTM) Adherence Claims Check-In claims $10 reimbursement Underuse $20 one time payment Require 14 day follow-up Monitoring programs $70 possible/med/year total MTM Adherence Monitoring Programs $10 quarterly adherence claims $30 year end bonus If patient is 80% adherent and patient was enrolled with all checkpoints completed through the year $70 total/med/patient/year 12/29/ /29/ Questions 12/29/

17 Exam Questions: 1. Which of the following terms best describes the duration of time a patient takes medication from beginning to end of therapy? a. Adherence b. Endurance c. Persistence d. Compliance 2. When considering the health literacy of our patient population, what percentage of US adults read below the 5 th grade level? a. 75% b. 64% c. 21% d. 5% 3. If a pharmacy benefits manager increases a copay from $10 to $20 for a prescription, which of the following is expected according to the American Medical Association survey? a. Adherence rates increase based on perception value b. Adherence rates decline by 10% c. Adherence rates decline by 50% d. No change is expected 4. What percent of prescriptions when prescribed by a physician, are filled, taken, and therapy is continued? a. 88% b. 73% c. 61% d. 47%

18 5. Which of the following disease states has the HIGHEST rates of adherence? a. HIV b. Infectious disease c. Osteoporosis d. Asthma 6. Which of the following disease states has the LOWEST rates of adherence? a. Cardiovascular b. Diabetes c. Asthma d. Sleep disorders 7. 56% of patients who received synchronized refills were considered adherent compared with nearly 90% of patients not receiving synchronized refills. a. True b. False 8. Equipp is an electronic quality improvement platform where plans and pharmacies can compare their patient results with established benchmarks and other pharmacies within their respective company. a. True b. False 9. Which of the following services can be used on a flip phone to get reminder text messages to increase medication adherence? a. Genie MD b. Pillboxie c. TextSmart d. ScriptYourFuture

19 10. Which of the following is not a pharmacy specific Medicare star measure with a high weighting? a. High risk medication use in the elderly b. Medication adherence for hypertension medications c. Plan Customer Service d. Appropriate screenings and vaccinations